“Getting Answers on Questionable Claims,” CLM Magazine

March 7, 2019

In an article published in the March 2019 issue of CLM Magazine, Ronni Bright and Marc Sirotkin discuss the importance of and best practices when investigating a questionable workers’ compensation claim and deciding whether to accept or deny the claim.

Bright and Sirotkin break the process down into five resources that employers can use to minimize abuse of the system, including:

Pre-Employment, Post-Hire Strategies: Employers should use pre-employment physicals and post-hire medical questionnaires, though in general, employers should stay away from asking prospective employees questions about their medical histories or prior accidents when interviewing candidates. However, employers can require employees to undergo a pre-employment physical and complete a post-hire medical questionnaire. This can help the employer establish the employee’s baseline health level.

Drug-Free Workplace Programs: A drug-free workplace policy, whether certified by a state board or not, may help the employer reduce exposure for work injuries. An employee testing positive for drugs after a work injury or refusing to take a drug screen following a work injury can potentially provide the employer with grounds to deny the claim.

Accident / Incident Reports: It is essential for the injured worker to complete an accident/incident report. The report should be a pre-approved form that allows the injured worker to document biographical details, the date/time of the accident, witnesses to the accident, the location of the accident and a description of injuries, along with pertinent details.

ISO ClaimSearch: Employers can access an injured worker’s prior claim history, including personal injury, motor vehicle and workers’ compensation claims in order to investigate with the insurer and medical provider the extend of prior accident and injury. This is important in handling aggravation injury claims and to find out if there is an intervening accident that break the causal chain to the compensable claim.

Medical / Hospital / Pharmacy Canvas: It is essential to perform a medical, hospital and pharmacy canvas search to confirm if an injured worker has been treated for a condition or injury prior to the subject accident date. This can help determine if a claim is truly the result of an idiopathic condition, if the injury was caused by a non-work-related condition, and whether a baseline condition for a compensable injury can be established.

“These five tools are inexpensive means to flag questionable claims and may potentially mitigate claims exposure,” said Bright and Sirotkin. “Some of the measures may also help reduce workers' compensation insurance premiums. The employer’s and the insurer’s/servicing agent’s proactive exercise of due diligence will certainly aid defense counsel in making a determination of the likelihood of successfully denying liability for the injury.”

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